Provider Demographics
NPI:1578629242
Name:THE WATERFORD PARTNERS CENTER, LLC
Entity Type:Organization
Organization Name:THE WATERFORD PARTNERS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:317-621-7475
Mailing Address - Street 1:5220 HIGHLAND RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5220 HIGHLAND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1913
Practice Address - Country:US
Practice Address - Phone:248-461-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI636931261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI636931OtherMI STATE LICENSE NUMBER
MI636931OtherMI STATE LICENSE NUMBER